NAM is the official provider of online scientific reporting for the
8th International AIDS Society Conference on HIV Pathogenesis, Treatment
and Prevention (IAS 2015), which will take place in Vancouver, Canada,
19th-22nd July 2015.

If there was a phrase that defined the 20th International AIDS
Conference (AIDS 2014), one that surfaced in every few presentations and kept turning up in
documents, it was “key affected populations”.

Although it has issued separate guidelines in
the past on key populations such as men who have sex with men, people who inject drugs, prisoners, sex workers and
transgender people. the World Health Organization (WHO) decided to make addressing the needs of key populations
the main focus of their 2014 document.

The primary attention it garnered then was a couple of
inaccurate reports in The Age (since
corrected) and Time that the WHO was saying that “All
men who have sex with men should take antiretroviral drugs”.

In fact, WHO says something a lot more cautious and
tentative, namely that the evidence suggests quite strongly that, for men who
have sex with men (MSM), “PrEP is recommended as an additional HIV prevention
choice within a comprehensive HIV prevention package”. (This also does not say
that the ‘comprehensive HIV prevention package’ must include a recommendation
only to use PrEP with condoms, as has also been alleged.)

The change from the previous guidelines is that they suggested
that PrEP should only be offered as part of the ongoing research programme into
this still new and hardly used method of HIV prevention. Now WHO is
suggesting, quite radically, that the evidence is sufficient for the world to
consider how it could move to enabling men who have sex with men to take PrEP. (It also adds that
PrEP should be considered for the HIV-negative partner in couples of different HIV
status, but this is not a new recommendation.)

Brazilian HIV and STI health director Fabio Mesquita was in
charge of the re-evaluation of the evidence for PrEP that found its way into
the new guidelines. He told a press conference at Melbourne: “The question no
longer is whether PrEP works, but whether we can make it available.”

The barriers to achieving the end of AIDS

As the conference proceeded and the new guidelines found their
way into numerous presentations and debates, it became apparent that their
radicalism covered a lot more than PrEP. WHO had issued its Consolidated guidelines on the use of
antiretroviral drugs for treating and preventing HIV infection only
last year, and they were structured in a way that has become familiar over the
last few years: around the “HIV care cascade”, the sequence of targets that
has to be hit – proportion tested, proportion in care, proportion on treatment,
proportion virally suppressed – if enough people living with HIV are to become
essentially non-infectious and turn the epidemic around.

These guidelines in themselves made new recommendations – that
HIV testing in the community and at home was as good as provider-initiated
testing, for instance – and increased the CD4 threshold for treating HIV to 500
cells/mm3.
But they were still written as an essentially ‘top-down’ approach to ending the
epidemic: if we get our programmes right, test enough people, fund enough
treatment, get as many people as we can on antiretroviral therapy, then the epidemic
will end.

During
the year, several events and some evidence suggested it might not be so simple.
Notoriously, anti-gay legislation was enacted or rather intensified in Uganda,
Russia and Nigeria, at least one HIV clinic was raided and at the Global Forum
for MSM and HIV (MSMGF) meeting before the main conference in Melbourne, evidence was presented showing that this was
already leading to MSM staying away from healthcare facilities.

Fascinating evidence was also presented at the conference that
HIV stigma and barriers to disclosure in some communities were such that simply
providing ART to people with HIV without counselling that supported disclosure
within their relationship might
lead to very poor adherence and viral suppression rates. This evidence came from
heterosexual couples, but may apply equally if not more powerfully to
populations that are more stigmatised and between whom talk of HIV status is
more fraught with problems such as criminalisation.

Guidelines that meet the needs of communities

Such events and evidence led WHO to be concerned that
“Without addressing the needs of Key Populations, a sustainable response to HIV
will not be achieved”.

Not only this: “To date, however, in most countries with
generalized HIV epidemics, the response has focused almost exclusively on the
general population. Even countries recognizing that HIV epidemics are
concentrated in key populations often are reluctant to implement adequate
interventions that reach those most in need.”

Furthermore: “In many settings HIV incidence in the general
population has stabilised or fallen. However, globally, key populations
continue to experience significant HIV burden” –
and yet “health data, including HIV prevalence data, are less robust for
key populations…due to complexities in sampling…legal concerns and issues
of stigma and discrimination. Laws criminalizing the behaviour of key
populations make it difficult to collect representative data.”

In other words, not only do the key populations bear a
disproportionate burden of HIV, we do not even know what that burden is because
it affects people afraid to be counted.

Therefore, although it has issued separate guidelines in
the past on key populations such as men who have sex with men, people who inject drugs, prisoners, sex workers and
transgender people, WHO decided to make addressing the needs of key populations
the main focus of their 2014 document.

Key populations, vulnerable populations

WHO makes a very clear distinction between Key populations and Vulnerable populations – one that was missed in some responses to
the document, which asked why groups such as adolescents and women were not
included.

WHO defines key populations as people who “due to specific
higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context” [WHO’s
emphasis]. In other words, they are at extra risk of HIV simply by being who
they are and doing what they do.

Vulnerable populations are people who “are particularly
vulnerable to HIV infection in certain
situations or contexts, [WHO’s emphasis] such as adolescents (particularly
adolescent girls in sub-Saharan Africa), orphans, street children, people with
disabilities and migrant and mobile workers. These populations are not affected
by HIV uniformly across all countries and epidemics.” However, they add, many
of the guidelines’ recommendations apply to them.

WHO adds that it is not sufficient to address the needs of
key populations: “They also are
essential partners in an effective response to the epidemic.”

Thus, Gottfried Hirnschall, WHO’s Director of HIV, told
the conference that in terms of specific changes to recommendations
there were not a lot of new ones in the new guidelines. The difference was that
for the first time the guidelines had been shared by a large and comprehensive
consultation exercise that had taken into account “The values and preferences
of the communities.”

Preventing overdose – naloxone packs

In fact, there is only one other specific recommendation that
is brand new in the guidelines (other than the recommendation on PrEP for MSM mentioned above). WHO
recommends, as it has done before, access to needle and syringe programmes and
to opiate substitution therapy, but adds a recommendation that people who inject drugs should be
provided with emergency packs of the heroin antidote naloxone for use by
friends or by the users themselves in case of accidental overdose.

WHO’s Philip Read told the conference that more people who inject drugs now
died of heroin overdoses than AIDS and that 60% of overdoses occur in front of
another person. Almost all the people who inject drugs interviewed for the WHO research
had at some time witnessed an overdose, and in the first year of a trial of
naloxone packs, 20% were used. This provision of ‘PEP for overdose’
could lead to substantial saved lives, he said.

Dismantling the critical disablers

Needless to say, such specific recommendations will not be
sufficient to save lives unless the structures that oppress key affected
populations are also dismantled. The first of the ‘critical enablers’ that will
be necessary to enact prevention for the key affected populations is that
“Laws, policies and practices should be reviewed and, where necessary, revised
by policymakers and government leaders, with meaningful engagement of
stakeholders from key population groups, to allow and support the
implementation and scale-up of health-care services for key populations.” The
others tackle violence, discrimination and other barriers to accessing care.

Rachel Baggaley, who was in charge of collating the evidence
that led to the recommendation on PrEP, said that healthcare worker attitudes
were also an important disincentive for key affected populations to come
forward for care. This had led to a
wasteful situation where there were parallel healthcare systems in many
countries, the government one and one run by community-based organisations
funded by non-governmental money that were consulted by the public
servants in charge of the country’s HIV strategy. This was often necessary to
deliver any services at all, but resulted in a blindness of governments to the
key affected populations in their midst and contributed to denial of their
existence or needs..

WHO, then, this year issued guidelines informed by a more
“bottom-up” consultancy process whereby the needs and opinions of the community
informed what HIV programmes should do. However, they were asked at a press
conference about the new guidelines, did this mean that the WHO had abandoned
the idea of 'universal test and treat' altogether, and were they ever going to
recommend that all people with HIV were offered treatment on diagnosis?

Can we finally treat our way out of the epidemic? 90/90/90

Another document was issued at the conference which took a
hopefully complementary approach towards solving the HIV epidemic. UNAIDS
issued for public consultancy – meaning it is not yet in its finalised form – a
discussion paper, Ambitious treatment targets: writing the
final chapter of the AIDS epidemic, which proposes the next aspirational target it wants to set for the world
to meet. This would be the 90/90/90 target,
meaning that by 2020 90% of all people living with HIV would know their status:
90% of those would be on treatment: and 90% of those would be virally
suppressed. This would mean that 72.9%
of the entire world population of people living with HIV would have an undetectable
viral load by 2020. If they did, then models predict the end of HIV as an
epidemic disease by 2030.

At first sight, this looks incredibly ambitious. Currently,
only 37% of people in the world with HIV receive antiretroviral therapy and
fewer in some areas such as eastern Europe (21%). And, as UNAIDS explains, previous
targets such as the last '15 by 15’ one (15 million people on ART by 2015) do
not capture the multistage cascade of achievements that need to happen in order
to achieve such a figure.

And yet: it looks as if the 15 by 15 target will be achieved.
“Targets promote accountability” say UNAIDS and the organisation’s Chief of
Special Initiatives, Badara Samb, said: “This is the kind of document that will
land in a health minister’s in-tray. Targets get remembered by politicians.”

Besides which, UNAIDS
says, targets “demonstrate that AIDS is a winnable fight.” In other words we
will only end AIDS if we believe we can.

What may be possible

UNAIDS believes the evidence suggests that it is possible to end AIDS. For
instance, there are a few countries in Africa – Ethiopia and Malawi for
instance – where already over two-thirds of adults have tested for HIV at least
once, and one, Rwanda, where over 80% have. In Latin America, an average of 70%
of people living with HIV know their status – though this varies widely from 43% in
Colombia to 80% in Brazil (and 90% in Cuba).

Retaining people on treatment has proved to be a challenge in
some areas but in Latin America and the Caribbean, it is estimated that of
those who are started on treatment, an
average of 80% are still on it two years
later (there are a couple of glaring exceptions, the small nations of the
Bahamas and Belize, where half of those who start treatment have dropped out
within a year: these exceptions are useful as sources of information on how to
do it better).

As for the third target of viral suppression, there is again a
wide spread of achievement in different countries. The 83% of people on
treatment who are virally suppressed in Rwanda shows what is possible: the less
than 45% cited by one researcher for Zambia shows what can happen without
proper support. Similarly, although viral suppression rates for people on ART
in Brazil and Mexico are 80%, in other countries such as Venezuela and Cuba,
that claim very high rates of retention in care, they hover around 50%. This exemplifies how the ‘treatment cascade’
approach can expose weaknesses in a system that has strengths in other places.

Hurdles to overcome

Achieving 90/90/90 will be a huge challenge. In sub-Saharan
Africa, for instance, only 29% of people living with HIV are currently virally
suppressed. One of the problems is that measuring viral suppression itself is
going to be a challenge: studies have shown that switching treatment
on the basis of CD4 counts or clinical symptoms can result in switching that is
either too soon (so wastes still effective drugs) or far too late (so maintains
people on therapies that aren’t working, creating sickness and drug
resistance). But viral load testing technology is still too expensive for low-income countries and UNAIDS admits there will still not be enough viral load
testing by 2020.

Another challenge is children: fewer children who need ART get
it than adults and only 10 of 29 currently available HIV medicines are approved
for paediatric use.

There are a number of 'elephants in the room' in the UNAIDS
discussion paper: glaringly absent are data from Russia and central Asia, the Middle East and indeed some of the upper-income countries that are failing to
treat their key affected populations, notably the United States. And some HIV campaigners believe that there
are structural problems ahead that may prevent UNAIDS from getting anywhere
near their goal.

One final question: there’s an inherent contradiction between ‘stretch
targets’ and ‘evidence-based recommendations’, and some WHO personnel expressed
reservations to aidsmap.com that the UNAIDS targets might be too far removed from the
latter. Evidence-based guidelines say: “Let’s do what we know works, and only
that” and the former uses what we know works as a springboard for what might work. It’s great to have
ambitions: but it’s important to adapt them if the evidence suggests they should
be different.

The perils of pushiness

Activist group, the International Treatment Preparedness
Coalition (ITPC) for instance, has released its own report on progress
towards the 2013 WHO guidelines that finds patchy progress in different areas
and, in particular, drug stock-outs and regulations that bar certain people from
treatment on a micro level.

But Christine Stegling, ITPC’s regional director, is concerned
not so much with what has been happening as with what may happen.

“Some of the rhetoric about AIDS simply doesn’t match the
reality of what’s on the ground. Not only are people not getting what they’re
entitled to, they’re not aware of what they should be getting because treatment
literacy is so low. There is very little grassroots awareness of the WHO
treatment guidelines and, of course, very few non-discriminatory services
tailored to the needs of key affected populations.

“We all like ‘stretch targets’ but you need to put them in
context. One of the biggest threats, ironically, is the economic progress some
countries are making: by 2020, 70% of the priority countries targeted by
providers like the Global Fund and PEPFAR will be in the middle-income bracket
which, according to current agreements, will deprive them of cheap generic
drugs. One of the big problems here is that the HIV activist community has such
low awareness of intellectual property rights and how we can work trade
agreements like TRIPS to our advantage.

“Generics won’t necessarily be cheaply available: many generic
companies have been bought by the big pharmaceutical companies whose motto
seems to be ‘If you can’t beat them, buy them’.

“We welcome the general aim of the UNAIDS targets, but we need
to ensure they are not insensitive and ‘pushy’: what is achievable for a
pregnant woman in Uganda may not be achievable for a gay man there, and even in
majority populations we are seeing really bad retention and drug resistance in
some programmes.”

Stepping up to the plate: will governments fund their own HIV programmes?

One answer to the ‘middle income’ problem of course is to tell
the governments of such countries to step up to the plate and pay for treating HIV
themselves. Although some countries with wealth like Nigeria are not only
failing to do this but actively persecuting their key populations, UNAIDS shows
in its discussion paper a very promising graphic that plots Asian countries’
per-capita GDPs with the proportion of their spend on AIDS that is domestic.

In the main the correlation is very strong. Thus, in the poorest
Asian countries like Nepal (per capita GDP US$690 a year) and Bangladesh ($752
a year) the proportion of AIDS funding contributed by the country’s own
government is only 1% and 8% respectively. In contrast, in well-off Malaysia
(per capita GDP $10,432 a year), 97% of AIDS funding comes from the Malaysian
government. Where countries’ AIDS spend is out of line, it tends to be in the
direction of over- rather than under-spending: in Thailand (per capita GDP $5480
a year), 85% of AIDS spending is domestic: the figure is very similar for China.
India (per capita GDP $1503, proportion of AIDS spend domestic 10%) falls
slightly below the line, but India has numerically the biggest HIV burden in
the region and also has a number of exceptionally well-financed HIV programmes
that are transitioning towards government funding.

In other words, in general, and with many exceptions, the
world seems to be meeting the financial challenge of AIDS. The question is:
will it meet the political and cultural challenges too?

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.